Master 2021 CPT® Changes With This Expert Overview

AAPC’s coding expert, Raemarie Jimenez, gives you the scoop on next year’s updates.

CPT® 2021 includes 206 new codes, 69 revised codes, and 54 deleted codes. All sections of CPT® received changes in codes and guidelines, except Anesthesia. The most significant changes are to codes for office/other outpatient evaluation and management (E/M), prolonged services, breast repair and reconstruction, cardiovascular shunting procedures, and COVID-19 testing. Here is an overview of the changes by section.

Evaluation and Management

New CPT® 2021 guidelines for office and other outpatient E/M services were created to reduce administrative burden on provider documentation and to align code selection with how providers practice medicine. This is the biggest change to E/M guidelines since the release of the Centers for Medicare & Medicaid Services (CMS) 1997 Documentation Guidelines for Evaluation and Management Services. E/M codes for office and outpatient services will be selected based on medical decision making (MDM) or time, effective Jan. 1, 2021.

Providers will no longer be required to document a certain level of history or exam to satisfy code criteria. It will be the provider’s decision what levels of history and exam are required to treat the patient.

The code descriptors for 99202–99215 are revised to include “medically appropriate history and/or examination.” The time designations were also revised in each code. For example, the descriptor for 99202 will be Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Tip: Because 99201 and 99202 have the same level of MDM (straightforward), 99201 is deleted.

The CPT ® 2021 guidelines include multiple definitions for key terms to support the new MDM table that is included in the 2021 CPT® code book. You will notice many similarities between the new MDM table and the table of risk currently used to determine the level of risk for the 1995 and 1997 Documentation Guidelines.

Time is redefined as total time instead of face-to-face time. The total time you will use for code selection includes the time spent by the provider on the date of service:

• Preparing to see the patient;
• Obtaining a history and performing an exam;
• Counseling and educating the patient/family/caregiver;
• Ordering medications, tests, or procedures;
• Referring and communicating with other healthcare professionals;
• Documenting in the health record;
• Independently interpreting tests (not separately reported) and communicating results; and
• Care coordination (not separately reported).

As with all time-based codes, time spent performing separately billable services should not be counted toward the total time for selecting the E/M code. For example, if the provider performs an EKG and reports 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report, you may not include the time the provider spent performing the interpretation in the total time for the E/M service. If they are not separately reporting 93000, however, you can count the interpretation time in the E/M service time calculation.

Important reminders:

• These changes only apply to the office/other outpatient services (99202–99215). For all other E/M sections and subsections (e.g., emergency department, consultations, hospital inpatient visits) continue to use the 1995 and 1997 Documentation Guidelines, where applicable.
• Use MDM or time to determine the correct code; you do not need to meet the requirements for both.
• When coding other E/M services, only continue to only bill based on time time when more than 50 percent of the practitioner’s time is spent counseling or coordinating care. Use either face-to-face time or floor time, depending on the E/M subsection.
• You may no longer report prolonged services codes (99354–99357) with 99202–99215. When the total time exceeds the highest level of E/M (99205 or 99215), use the new prolonged services code 99417 Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure … for each additional 15 minutes. There is a table provided in CPT® to assist with proper code use. Also in this subsection, there is a comparison chart for all the prolonged services codes.

Surgery: Integumentary System

The CPT® 2021 guidelines for breast repair and reconstruction codes 19316–19396 are revised to provide a clearer description of the different techniques. A reconstruction can include a single technique or multiple techniques. In addition to extensive guideline revisions, 19324 and 19366 are deleted and 15 codes are revised.

Codes 11970 and 11971 are revised to clarify the replacement and removal of tissue expanders as follows:  

11970    Replacement of tissue expander with permanent implant

11971   Removal of tissue expander without insertion of implant

Because of the myriad changes in this section, a thorough review of the breast Repair and/or Reconstruction subsection is required.

Surgery: Musculoskeletal System

New guidelines are added to the Endoscopy/Arthroscopy subsection to define the size required to report the removal of loose body(ies) or foreign body(ies). According to CPT®, in order to report the removal, the body(ies) must be “equal to or larger than the diameter of the arthroscopic cannula(s) used for the specific procedure, and can only be removed through a cannula larger than that used of the specific procedure or through a separate incision or through a portal that has to be enlarged.”

Arthroscopic shoulder debridement codes (29822–29823) are revised to define the difference between a limited versus an extensive debridement: One or two discrete structures is limited, and three or more discrete structures is extensive. The code descriptors include examples of discrete structures “humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies].”

Surgery: Respiratory System

Code 30468 Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) is added to report the repair of a nasal valve collapse using a minimally invasive technique to open the collapsed passage with absorbable lateral wall implants.

Percutaneous needle biopsy of lung or mediastinum (32405) is deleted and replaced with new code 32408 Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed. Note that this code bundles imaging guidance with the procedure. New guidelines are added preceding code 32408 to define a core needle biopsy and a fine needle aspiration and provide cardiology coders instructions for proper reporting of these codes.

Surgery: Cardiovascular System

CPT® 2021 includes three new shunting procedure codes for congenital cardiac anomalies (33741, 33745, 33746). Introductory guidelines are also added.

• Code 33741 is for transcatheter septostomy to create effective arterial flow. The procedure includes imaging guidance when performed. A diagnostic cardiac catheterization is not typically performed during this procedure; therefore, it can be reported separately when performed.
• Code 33745 is for transcatheter intracardiac shunt creation using a stent for effective intracardiac flow. The procedure includes intracardiac stent placement, target zone angioplasty, diagnostic cardiac catheterization, and imaging guidance when performed.
• Code +33746 is an add-on code for use with 33745 for each additional shunt location.

Insertion of ventricular assist device codes (33990, 33991) are revised to specify that the procedure involves the left heart. New code 33995 Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only reports the insertion of ventricular assist device in the right heart. Code 33992 is revised to report the removal of the ventricular assist device from the left heart. New code 33997 Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session from insertion reports the removal of a ventricular assist device from the right heart. Introductory guidelines are added to the Cardiac Assist subsection to provide clarification for proper use of the codes.

Surgery: Male Genital System

New code 55880 Ablation of malignant prostate tissue, transrectal, with high intensity-focus ultrasound (HIFU), including ultrasound guidance describes the transrectal ablation of malignant prostate tissue using HIFU. The procedure includes imaging guidance when performed.

Surgery: Female Genital System

New add-on code +57465 describes the computer-aided mapping of abnormal areas of the cervix. This procedure is performed with colposcopy procedures. There is a parenthetical note indicating the proper primary codes with which to use this new add-on code.

Surgery: Nervous System

Injection codes 64455, 64479, 64480, 64483, and 64484 are revised to be child codes to the parent code 64400.

Radiology

Radiology coders: Thorax computed tomography codes 71250, 71260, and 71270 are revised to include “diagnostic.” And a new code (71271) is added to report low-dose thorax computed tomography (CT) for lung cancer screening.

Antegrade urography (74425) is revised to remove “pyelogram, nephrostogram, loopogram” to avoid confusion. A new parenthetical note lists the appropriate codes you can report with 74425.

New code 76145 is for reporting medical physics dose evaluation for radiation exposure that exceeds the institutional threshold.

Pathology and Laboratory

You’ll find several new codes in the Therapeutic Drug Assays subsection. The new codes include 80143 (acetaminophen), 80151 (amiodarone), 80161 (-10,11-epoxide), 80167 (felbamate), 80181 (flecainide), 80189 (itraconazole), 80193 (leflunomide), 80204 (methotrexate), 80210 (rufinamide), and 80179 (salicylate).

Due to frequent use, several molecular pathology Tier 2 codes are now Tier 1 codes. A few examples include 81168, 81278, and 81279.

There are also new codes to report COVID-19 testing, all of which went into effect in 2020. The early release of these codes was needed to report the different tests being performed. There are new codes for single-step immunoassay antibody detection (86328) and multiple-step immunoassay antibody detection (86769). Code 87635 is added for infectious agent detection with nucleic acid probe. Code 0202U is used to report pathogen detection.

There are also many new proprietary laboratory analyses (PLA) codes. These codes describe PLAs provided by either a single laboratory or licensed/marketed to multiple providing laboratories. This subsection includes multianalyte assays with algorithmic analyses (MAAA) and genomic sequencing procedures (GSP).

Medicine

There is a new rabies immune globin code (90377) to report heat- and solvent/detergent-treated (RIg-HT S/D) human doses, administered intramuscularly.

Codes for retinal imaging for detection or monitoring of diseases (92227, 92228) are revised. Code 92227 is reported when the service is provided by remote clinical staff, and 92228 is reported when performed by a remote physician or other qualified healthcare professional. New code 92229 is appropriate to report when the test is performed as a point-of-care automated analysis.

Category III codes for external electrocardiographic recording (0295T, 0296T, 0297T, 0298T) are converted to Category I codes (93241–93248). Choose between these codes based on the amount of time of the recording. For recordings from 48 hours to seven days, report 93241, 93242, 93243, or 93244, depending on the component of the service being performed. For recordings more than seven days and up to 15 days, report 93245, 93246, 93247, or 93248, depending on the component of the service being performed.

Category III Codes

There are many new Category III codes created for new and emerging technology. Some examples include noncontact real-time fluorescence wound imaging (0598T, 0559T), remote optical coherence tomography (0604T–0606T), and breast CT including 3D rendering (0633T–0638T).

Learn More About CPT® Updates

For training and application of the CPT® code changes for 2021, please join us for AAPC’s hands-on virtual workshop on Dec. 1.